Laparoscopic prosthetic hiatal reinforcement for large hiatal hernia repair

Large hiatal hernia (LHH) is defined by a hiatal defect larger than 6cm; repair is indicated whenever it becomes symptomatic. As the risk of recurrence after most techniques is relatively high, laparoscopic repair with prosthetic reinforcement of the hiatus has been proposed to reduce the recurrence rate. Our technique and outcomes are reported.

Laparoscopic prosthetic hiatal reinforcement was performed in 58 patients between August 1997 and October 2009. Prolene(®), Mersilene(®), Goretex(®), and Parietex(®) were the four types of prosthetic material used. Since January 2004, the double-sided V shaped Crurasoft(®) mesh was introduced. Surgical evaluation was based on anatomical and functional criteria: the anatomical results included the presence of recurrent hiatal hernia or esophageal stricture as evaluated by an upper gastrointestinal (UGI) series; functional evaluation was based on a questionnaire concerning long-term patient satisfaction according to the Visick score. Median follow-up was 51 months.

Postoperative UGI series were performed during the initial hospitalization in 37 patients: results were judged to be satisfactory. A routine follow-up UGI series was obtained at 8 months and one year in 46 patients. Two patients underwent reoperation for lower esophageal stricture at 6 months and 16 months. Forty-five patients (77.6%) were reevaluated. Of these, 29 patients (64.4%) were free of symptoms with a good quality of life, eight patients (17.7%) complained of moderate dysphagia and two patients (4.4%) had severe dysphagia. Four patients (8.9%) had moderate pyrosis while severe pyrosis requiring long term PPI treatment was observed in three patients (6.7%). No prosthesis-induced ulceration or perforation was noted. Late follow-up UGI series, performed in 21 patients, showed two patients with severe stricture and a single case of recurrence, but neither of these patients required surgical management.

The addition of mesh reinforcement to surgical repair of large hiatal defects is safe and beneficial in terms of quality of life.